Training Programs
Audits & Assessments
Regulatory MonitoringArchive for April, 2009
CMS issues updated lab NCD manual
CMS has posted the April 2009 version of the NCD manual for clinical diagnostic laboratory services on its Web site.
FAQ: May an Advanced Beneficiary Notice (ABN) be utilized to bill the beneficiary for services denied due to an MUE?
A provider/supplier cannot bill the beneficiary for services denied due to an MUE. An MUE denial is an initial determination based on a coding denial, not a medical necessity denial. By statute an ABN may be applied only if the initial determination on a claim results in a denial due to medical necessity. If a provider appeals an MUE denial and some UOS are denied as not medically necessary, the provider should NOT apply an ABN to bill the beneficiary. An appeal is not an initial determination, and by statute the ABN provision only applies to the initial determination.
CMS has issued a fact sheet titled General Equivalence Mappings: ICD-9-CM to and from ICD-10-CM and ICD-10-PCS in which it addresses the top 10 questions and answers. Topics include cases in which there is a one-to-one map as well as those in which there is no translation between the two systems, as well as a variety of others. Hospitals must implement ICD-10 no later than October 1, 2013.
EHR implementation and computerized physician order entry (CPOE) are top priorities for health information technology (IT) professionals, according to the 20th annual Healthcare Information Management and Systems Society (HIMSS) Leadership Survey. HIMSS announced the results of the survey in an April 3 press release.
Of the 304 respondents—many of whom responded prior to President Obama’s February 17 signing of the American Recovery and Reinvestment Act of 2009—31% said the primary focus would be ensuring their organization has a full EMR. Seventeen percent said the primary focus would be the installation of a CPOE. To assess the effects that the ARRA will have on HIT spending, HIMSS is gathering additional information from survey respondents, according to the press release.
"The economy is affecting all sectors, healthcare IT included, but the good news is healthcare IT still continues to grow," said Charles E. Christian, HIMSS board chair, in the press release. "With the passage of the ARRA, the resulting billions of dollars intended to stimulate healthcare IT should certainly impact how respondents view their budget options."
304 participants completed the self-administered Web-based survey between February 1 and March 6. Those surveyed represent 250 unique healthcare organizations and nearly 700 hospitals throughout the United States. The average bed size of the hospitals was 519. Approximately 80% of respondents said they are senior information technology executives at their organizations, and 62% are corporate chief information officers.
NEW!
Recordings of the following Recovery Audit Contractor Defense: A RAC Readiness Summit conference sessions are available via CD or MP3:
- From the Field: A Panel Discussion. Our esteemed faculty will share their stories, experiences, challenges and victories with the RAC demonstration project. Their goal is to help you prepare by providing tested recommendations.
- A Team Approach to Manage Medical Necessity. This session covers ways to integrate case management; reviewing physician orders for medical necessity; setting up criteria in the emergency department; ensuring that criteria are met for one-day stays and observation; proper use of the Medicare Secondary Payer Questionnaire; data mining opportunities to determine risk areas; components and typical documentation errors of rehab medical necessity; implications of RAC for rehab services admissions and documentation; and optimizing the role of case management and physician advisors.
- Insourcing vs. Outsourcing: Weighing Your Options. Our faculty will set the stage for the pros and cons of handling RAC requests internally or externally. This session addresses staffing requirements; ensuring a solid understanding of what’s in the medical record; and coordinating with physicians when appeal letters must be written using the insourced model. For the outsourced model, the session covers how to make the call to outsource the requests and appeals; and questions to ask when selecting a vendor.
- Strategies for Coding Compliance. This session will cover analysis of top areas found in demonstration project, including debridement and septicemia; how to conduct proactive audits and ensure proper documentation for medical necessity.
- Monitor One-day Stays Under RAC Scrutiny. One-day and short stays were heavily scrutinized in the demonstration program and will likely continue in the permanent program. In his session, Yvonne Focke, RN, BSN, MBA, and Robert R. Corrato, MD, MBA, will explore how you can help your organization put processes in place to admit appropriately; ensure appropriate physician documentation for medical necessity; create admissions monitoring by case managers; and enforce emergency department compliance with admissions criteria.
- Mastering the Appeals Process. Our faculty provides a thorough discussion of how to appeal RAC determinations. The session will cover levels of appeal, choices regarding what to appeal, timelines and guidelines on operationalizing the process, as well as assessing what it will take financially and from a staffing perspective to do so.
Editor’s note: “Recovery Audit Contractor Defense: A RAC Readiness Summit” was held March 19-20, 2009 at the Renaissance Glendale (AZ) Hotel & Spa. Bonus resources included with each session. Visit HCMarketplace for more information.
- On contingency fees: RACs receive the same contingency fee regardless of whether they identify over- or underpayments.
- On medical record request limits: If your medical record request limit is per NPI, listen up. The record request limit is based on your group NPIs, not the number of NPIs assigned to your individual physicians. This could be an issue, explains Nancy Beckley, MS, MBA, CHC, of Bloomingdale Consulting Group, Inc. “An 18-member physician practice group that has a group NPI could expect requests of 50 medical records every 45 days, whereas if this same medical group issues a different group NPI to each of its three practice locations (each of which have six doctors), the physician practice group could have up to 30 medical records requested for each of the three groups—for a total of 90 medical records every 45 days.”
- On line-item billing: For a claim containing multiple CPT codes for the same date of service, each code (i.e., procedure) constitutes an item that RACs can review. Beckley believes this may come as a surprise to many providers who may consider a visit (which could encompass several CPT codes) as a claim for a date of service.
- On submitting electronic claims: The RACs currently aren’t set up to receive electronic data interchange—nor will they be for some time. For now, submit paper claims (via fax is fine) or send images of electronic medical records via CD or DVD.
- On outreach sessions: If you are in a blue state, you will start seeing outreach sessions in your area beginning in August. If you are a yellow or green state, you should see sessions in your area soon. CMS will update its outreach schedule as it adds sessions. If you are a yellow or green state and believe CMS has no outreach sessions applicable to your organization in your area, e-mail CMS at RAC@cms.hhs.gov. CMS also plans to provide an outreach presentation on its Web site. CMS acknowledged during the call’s Q&A section that hospital associations and medical societies hosting the provider outreach sessions may have limited participation to “members only” leaving nonhospital or nonphysician providers (e.g., physical therapy clinics or DME providers) without an opportunity to attend a session, says Beckley.
- Does your utilization review (UR) plan reflect a compliant process to meet the UR standards of the Conditions of Participation?
- Is there valid and documented physician medical necessity decision-making occurring?
- Are you following guidance put forth by CMS contractors?
- Is the UR staff appropriately meeting its daily operational admission screening criteria accountabilities? Is the UR staff incorrectly applying or going outside of the strict application of screening criteria?
- Is there ongoing education for UR staff in the use of screening criteria?
- Is there inter-rater reliability testing and quality assurance (QA) of screening criteria review by UR staff?
- Are UR screening criteria being applied to all Medicare beneficiaries in the hospital?
- Are admission review results documented in an auditable fashion and placed within the patient chart?
- Are secondary physician review determinations based upon the evaluation of regulatory guidance?
- Is there communication between the physician making the secondary physician review determination and the treating physician?
- Is there continuing education of physicians making secondary physician review determinations to ensure application of up-to-date clinical evidence and regulatory guidance?
- Is there inter-rater reliability and QA testing of the secondary physician review?
- Does the chart documentation reflect the secondary physician review determination and the process?
- Is there a process to ensure that the physician order is consistent with the admission status determination?
- Is there a process to ensure that the treating physician, hospital, and beneficiary are aware of final claim status before patient discharge?
Waits, delays, and cancellations are so common in healthcare that patients and providers have come to expect waiting as part of the care process. But poor patient flow can have seriously adverse effects on patient outcomes and your facility’s bottom line—and can even increase your susceptibility to RAC audits.
According to Kelly Cooke, MSN, RN, the director of clinical resource management, social work, and documentation improvement at the Hospital of the University of Pennsylvania, part of maintaining optimal patient flow is placing patients in appropriate level of care and creating a system that guards against readmissions.
“If you can initially place your patients in the appropriate level of care, this will enable your facility to have a very successful RAC audit,” says Cooke. In addition to up-front processes, she recommends creating strategies to prevent unnecessary readmission.
Editor's note: This article is an excerpt from HCPro’s newest resource for hospital case managers—www.CaseManagementMentor.com—a free online blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices. Visit the blog to read the complete article.
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